Posttraumatic Growth Syndrome: Fact or Fiction?

Her grief was unremitting, and after more than 2 years, she began psychotherapy with a psychiatrist who also prescribed an antidepressant. "He said I had a major depression-no energy, couldn't sleep, and continued to cry much of the time." Her recovery was gradual, and she described it in the following way: "The therapy helped, but several different antidepressants didn't seem to do anything but cause side effects. What really made a crucial difference was mostly spiritual." She went on to describe the support she received from her priest and congregation and an intensification of her previous religious belief system that centered on a deeper relationship with God.

Although the major depression did not totally remit for 4 years, she has been symptom-free for 16 years. Indeed, she believes that she has been functioning at a higher level psychologically than ever before. "I think I'm more confident and independent than when I was married, and I also believe I'm better with people-more empathic and caring. I look forward to formalizing my helping by becoming an ordained deacon."

More than one fourth of interviewed Episcopal aspirants have described a severe life crisis and its resolution as a significant part of their callings. Most of them have described dysfunctional families of origin (often severely so) and have experienced physical and/or sexual abuse. Many have histories of sequential relationship failures. Although this group of nonclinical subjects emphasized the spiritual component of their recovery and experienced growth, my earlier in-depth interviews with research volunteer subjects revealed a significant minority who also described previous major life crises (most often major depression), recovery, and self-experienced psychological growth without noting a spiritual component.

This essay focuses on what to make of self-reported growth following trauma. As will become clear, there are 2 opposing views among those who study the aftermath of serious trauma. One holds that having experienced growth as a consequence of trauma is an illusion that is central and helpful to the process of coping. The opposing view is that the reported growth is real and that the changes reported are accurate accounts of changes in the self.

The published literature on this topic is huge, and a comprehensive review is not possible here. Rather, I write about this topic because much of what is written is not published in journals that are usually read by clinicians. Further, many clinicians are appropriately concerned with posttraumatic stress syndrome and how to better understand and treat this often devastating disorder. There is also the issue of sampling: clinicians see patients and not nonclinical subjects whose life narratives are more likely to contain accounts of psychological growth through adversity and suffering. Finally, there is the concern that acknowledging that some students of trauma believe that the self-reported growth is real may in some way be used to demean those in whom posttraumatic stress syndromes develop.

The position of those who endorse the coping perspective is illustrated by the work of Janoff-Bulman,¹ who is a major theoretician of trauma and its consequences and reports on her own research and that of others. Her major stance is cognitive-social. All persons, to one extent or another, hold basic assumptions (conscious or unconscious beliefs) about themselves, the external world, and the relationship between the two. The 3 fundamental assumptions are that one's personal world is basically benevolent, that life makes sense (order and meaning), and that one is worthy and in control. It is these core assumptions that are overturned by severe and especially random trauma, and it is the struggle to reconstruct these adaptive illusions that is at the core of the coping process. It is the confrontation with one's own survival-whether resulting from serious accidents, natural disasters, disease, or criminal attacks-that is the defining feature of the trauma. One is forced to recognize his or her deepest vulnerability. In taking this position, Janoff-Bulman adopts an overtly existential stance. Denial and intrusive recollections are considered within certain limits to have adaptive value. They are often part of the coping process and allow the victim to work gradually on reconstituting a changed assumptive world. For some survivors, the need to talk-to become the active storyteller-can also be understood as adaptive.

There are also 3 major cognitive strategies. The first is comparing experiences favorably with those of real or imagined other victims. The second is an element of self-blame. Here, a distinction is made between characterological self-blame and the transient self-blame that reflects an adaptive effort to reduce the randomness (and meaninglessness) of the traumatic event. The third cognitive strategy is finding some benefit in the traumatic experience. Most commonly, these self-interpretations involve lessons about life (how precious it is) and the self ("I am now more compassionate and caring"). Such interpretations are adaptive in that they help restore meaning to life.

Janoff-Bulman's data support the fact that most trauma victims recover in the sense of reestablishing a new and reasonably comfortable assumptive world that incorporates their dreadful experience. However, the trauma is permanently encoded; some degree of disillusionment remains. Thus, this body of careful research and complex theorizing ends on a positive note. It is not, however, the "better than before" that is central to the concept of posttraumatic growth.

Alternatively, the opposite view (that the changes reported following trauma are real and that there is a posttraumatic growth syndrome) is supported by equally competent researchers and theorists. The example I shall use here is the work of Tedeschi and Calhoun,² who emphasized that the suffering and struggle resulting from the trauma is necessary for growth to occur. The empirical evidence for growth is supported by the sameness of reported changes across many studies. These are a changed sense of self in which, for example, one is both (and paradoxically) more vulnerable and more self-reliant; has a greater emphasis on empathic, caring relationships with others; and has a changed perspective on the meaning of life.

Tedeschi and Calhoun also suggest that certain personality characteristics predispose some persons to grow as a result of their struggle with trauma. Dispositional optimism, cognitive complexity, internal locus of control, and extraversion are emphasized. They speculate that the relationship between personality and growth through adversity may be curvilinear-that is, it is neither those persons with very high or very low levels of pertinent personality characteristics who are most likely to grow.

For the most part, Tedeschi and Calhoun emphasize the same crucial coping processes as does Janoff-Bulman. The ultimate outcome is determined by the repair of cognitive schema (adaptive illusions) and by the reworking of a life narrative in which the trauma and response occupy a central place. Tedeschi and Calhoun² write, "There is nothing new or remarkable in the assertion that psychological growth can be precipitated by the pain of unfortunate events. What we have found new and remarkable is how often this happens and how apparently ordinary people achieve extraordinary wisdom through their struggle with circumstances that are initially aversive in the extreme."

One of the problems for clinicians is how to interpret these different views. There are systematic studies that support both positions. I recommend Tennen and Affleck³ for a thoughtful and balanced overview. They believe that there are too many unanswered questions about the concept of posttraumatic growth to come to a definitive answer. Longitudinal studies (with their possibility of pretrauma measurements) are badly needed. There remains much to learn about personality predispositions, sudden versus gradual change, reported sex differences (women are more likely to report benefits and growth), and those aspects of personality that struggling with trauma may change.

In the beginning of this essay, I emphasized that the voluminous literature about this topic is mostly reported in journals and books that are not ordinarily read by clinicians whose major focus is on posttraumatic stress syndromes. The purpose of this essay is to call to the attention of clinicians that there is a vigorous and ongoing academic debate involving suffering and its consequences. The old adage, "What doesn't kill you makes you stronger," continues to attract the attention of serious students of trauma and its consequences.

References:

References

1.

Janoff-Bulman R.

Shattered Assumptions: Towards a New Psychology of Trauma.

New York: Free Press; 1992.

2.

Tedeschi RG, Calhoun LG.

Trauma and Transformation: Growing in the Aftermath of Suffering.

Thousand Oaks, Calif: Sage Publications; 1995.

3.

Tennen H, Affleck G. Personality and transformation in the face of adversity. In Tedeschi R, Park C, Calhoun L, eds.

Post-Traumatic Growth: Positive Changes in the Aftermath of Crisis.

Hillsdale, NJ: Erlbaum; 1998:65-98.